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Please provide the following applicant information to request an eRA Commons user account.

Provide a response for ALL of the required fields.

If a field is not relevant, please enter "NA" as your response for that field. Submit the completed form data using the 'Submit" button provided at the bottom of the form.

One (1) applicant per form.

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Requestor Information. (Person submitting this request)

Requestor Name:

* must provide value

Requestor email:

* must provide value

Requestor Phone Number (Example: 415 555 1212)

* must provide value

Applicant Information

Applicant's Full (Legal) name

* must provide value

If applicant has ever used a different name or alias, please provide the different name.

* must provide value

Applicant's UTSW assigned Person ID (PID) number.

(NOTE : This PID number is not a Student ID number. If you do not know your PID number, please access iAIM to locate it witin your Job information, or consult administrative staff within your sponsoring academic department.)

* must provide value

Applicant's Birthdate (mm/dd/yyyy)

* must provide value

&nbsp&nbsp Y-M-D

Mentor's name (if applicable).

* must provide value

Is this request for a non-PI user account only (i.e., NOT a PI, Co-PI, Key Person, Fellow, or Post Doc)?

If the applicant is a Lab Tech, Assistant, or Office Administrative Personnel, the response should be "Yes".

If the applicant received previous federal funding as a PI for a grant, please provide the following information from the most recent funded grant.

If these fields do not apply in relation to the applicant, mark them with "NA".

Funded grant (IC) Institutional Code (2-digit organization code).

* must provide value

Funded grant serial number.

* must provide value

If the applicant was a PI at a previous organization AND had an eRA Commons user ID for that organization, please provide the following information.

If these fields do not apply in relation to the applicant, mark them with "NA".

Previous email address used in existing Commons user profile.

* must provide value

eRA Commons PI user ID from previous organization.

* must provide value

Name of previous organization.

* must provide value

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